Any major SIGN/SYMPTOM of sepsis - PowerPoint Presentation

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Any major SIGN/SYMPTOM of sepsis

Any other SIGNS/SYMPTOMS of sepsis

Symptomatic sepsis

Asymptomatic sepsis

48 hours of IVAB

7-10 days. Stop day 7 if clinically well

5 days of IVAB

Malawi

Other LICs

Sepsis unlikely

A

Any major RISK FACTOR of sepsis

Any other RISK FACTORS of sepsis

Yes

No

>1

0 or 1

Yes

No

>1

0 or 1

Neonatal Sepsis Algorithm

Risk factors

MajorMaternal fever >38°C in

labour Prolonged rupture of membranes (PROM) >18 hours

Foul smelling amniotic fluidOther risk factors

<32/40 weeks gestation or <1500g (spontaneous labour only)

Signs/symptoms

MajorNeonatal temperature >37.5 °C

Boil/abscessGrunting/severe respiratory distress/ mod-severe WOB

LethargyUmbilical redness extending to the periumbilical skin or umbilicus draining pus

Deep jaundice: palms and soles of the baby deep yellowTachypnoea > 60 bpm

Convulsions/twitching or abnormal movementsMany or severe skin pustulesBilious vomiting with severe abdominal distension

Bulging fontanelle New onset of poor feeding

Not moving when stimulatedSwollen red eyelids with pus

Central cyanosisOther signs/symptoms

Pallor

Neonatal Sepsis Algorithm

Antibiotic doses

Gentamicin (IM/IV)

<7 days: 3 mg/kg (LBW) and 5 mg/kg (normal BW) per dose once a day

>7 days 7.5 mg/kg once a day Ampicillin (IM/IV)

<7 days: 50 mg/kg every 12 h >7 days every 8 h Benzylpenicillin (penicillin G) (IM)

<7 days: 50 000 U/kg every 12 h>7 days every 6 h

Supportive care

Thermoregulation: aim for 36.5-37.5 °CProvide respiratory support oxygen or CPAP as needed according to CPAP algorithm

Check blood glucose and provide feeding support as neededConsider 10ml/kg fluid bolus if shocked as per SHOCK algorithm

Consider 2.5mls/kg 10% dextrose if BS<2.5 mmol or 45 mg/dl – as per HYPOGLYCAEMIA algorithm

Neonatal sepsis management

 Investigations

If possible

perform sepsis screen: FBC, CRP, blood culture

LP only for those who have clinical signs of meningitis (but stable) or late-onset neonatal sepsisAntibiotic choices

1st line: give local recommendationsIM/IV gentamicin and benzylpenicillin or

ampicillin 2nd line: If no improvement after 48 hours change to a third-generation cephalosporin

IV cloxacillin and gentamicin if greater risk of staphylococcal (skin infection).

Antibiotic duration (without investigations)Asymptomatic sepsis: T

reat for 48 hours and stop if well (Treat for 5 days in Malawi)Symptomatic sepsis: Stop at day 7 if clinically well otherwise continue for 10 days

Any one risk factor

Foetal distress

Resuscitation: Assisted ventilation >5 minutes or CPR >10 minutesApgar at 5 minutes <7

Any one sign or symptom

ComaConvulsions

LethargyHypotonia

Absent Moro reflexAbsent suck

Respiratory distress

No

Perform

Thompson score

to assess for HIE

No

Unlikely HIE

>37 weeks gestation

Consider

HIE but seek clinician review to confirm diagnosis

No

Yes

Hypoxic

Ischaemic

Encephalopathy Algorithm

Yes

Yes

Management page for HIE

Thermoregulation

Aim for normothermia

Avoid hyperthermia and hypothermia

Respiratory support

Give respiratory support as appropriate. Give oxygen if saturations <90% in air

Feeding

support, anticonvulsants and antibiotics

Give feeding support as appropriate1. Oral feeds (breast feed or bottle if breastfeeding is not possible)

2. Give NG feeds if BS <2.5mmol/L or <45mg/dL and not tolerating oral feeds3. Give IV fluids if BS <2.5mmol/L or <45mg/dL and not tolerating NG feed

If evidence of seizure activity give Phenobarbitone

as per convulsions algorithm.

Reassess suck, tone, coma, seizures every 8 hours for 72 hours in hospital

Treat for sepsis with antibiotics

Any one or more signs or symptoms of respiratory distress

Saturations in air <90%

Tachypnoea >60 bpm

Fever >37.5⁰C or <36⁰C and crepitations on auscultationGrunting

RecessionsAny increased work of breathingCyanosis

Apnoea

Respiratory Distress of the

Newborn

(RDN)

Unlikely RDN

No

Yes

Management

Respiratory Distress Algorithm

Teaching page

for RDN

Meconium aspiration

Consider if meconium stained amniotic fluid

Just because there was meconium at delivery doesn’t mean it was aspirated.

Most aspiration occurs in utero before the baby is born, so more likely if there was foetal distress in labour or has signs of birth asphyxia.

Floppy babies with severe HIE and meconium aspiration are unlikely to benefit from CPAP.

Transient tachypnoea of the

newborn (TTN)These babies are not unwell

RR is usually between 60-80 bpm and they don’t usually need oxygenThis should resolve in the first few hours of life.

TTN is more likely following elective C-section or a rapid vaginal delivery.Give antibiotics if unable to exclude other causes

i.e no chest xray

Respiratory distress syndromeConsider if < 37 weeks or diabetic mother

Benefit from CPAP see AlgorithmCongenital Pneumonia

Consider if temperature > 37.5 ⁰ c or < 36 ⁰ c and crepitations on auscultation

Risk factors for sepsis i.e maternal fever/PROM/foul smelling amniotic fluid

Management page RDN

Investigations

Perform a chest x-ray if it will change management

or if the infant is not

improving as expected or deteriorating.

Airway and respiratory support

Position airway

Give oxygen if oxygen saturations < 90% in air

If > 1kg consider CPAP according to CPAP algorithm

Feeding support

If breathing 60-80 bpm use cup/NGTIf needing CPAP use OGTIf breathing > 80bpm consider IV fluids

IV Access for Antibiotics

Give antibiotics including for suspected TTN (unless have chest x-ray and can safely exclude.)

Hypothermia

Mild = 36-36.4

°C

Mod = 32-35.9

°C

Severe = <32

°C

Hypothermia management page in

NeoTree

:

Warm the baby

S

kin to skinP

lace on warmer/resuscitaire

if unstable 

Limit heat loss

Make sure the baby is dry

Put on a hat and wrap up the baby

If on the resuscitaire

put the sides up

Ensure room is free from drafts - windows and doors closed

MonitorRecheck

temperature every 30-60 minutes until normothermic

Watch out for overwarming

Complete NeoTree assessment to assess for signs of infection (consider if persistent hypothermia despite warming),

apnoea and

hypoglycaemia.

Temperature <36.4

°C?

Yes

No

Temperature >37.5

°C?

Yes

If fever persists follow NEONATAL SEPSIS algorithm

No

Normothermia

Recheck temp every 30-60 mins

Address any environmental causes: unwrap or remove baby from under

resuscitaire

Hypothermia Algorithm